The course of a phobia depends on the fate of the unconscious conflict that underlies it. If there is a shift in the balance of the contending elements, the phobia may be alleviated. So, for instance, the phobia of a very young child may disappear spontaneously when the child progresses in toilet training. This is when his ego function of control has grown in his natural development. A girl, at puberty, may suffer from street phobia (agyiophobia).
She may lose this fear when she has acquired greater comprehension of the new qualities of her sexual urges and when she has adapted herself to the rules that govern her adolescent society, i.e., when her ego and superego have found a way of dealing with the public increase of her ID drives. A phobia may remain more or less static throughout life, except for some modifications produced by encounters with the new demands of living. A claustrophobic or acrophobic who has never known he is afraid of flying may discover it only when faced with the opportunity to fly.
A phobia may grow more severe as an ever-widening range of objects and situations stimulate internal conflict. Ever-larger areas of functioning must be avoided to keep them free of anxiety. Such a patient may renounce any activity that leads him out of the house or even out of bed. This aggravation of symptoms will need to be traced back to the underlying conflict.
Any rational or even irrational treatment of a phobia must influence the forces involved in the underlying conflict. Or it must act upon the conflict’s anxiety.
Anxiety is a central phenomenon in phobias. Therefore, drug therapy that effectively diminishes anxiety may alleviate a phobic symptom without removing its causes.
The training of a child, i.e., the strengthening of its ego through benevolent educational measures, may favorably influence the balance of forces in conflict. The reinforcement of positive moral strivings (strengthening of ethical convictions) may help to subdue emerging undesirable instinctual impulses.
The psychiatrist who applies any or all of these techniques may help the patient considerably in his effort to gain control over his phobic state. The objective of psychoanalytic treatment—from which phobias evolved—is to achieve a new, more stable balance between the three conflicting mental structures:
(1) it attempts to free ID drives’ adult qualities from their bounds;
(2) it increases the tension tolerance of the ego, thereby giving skills and comprehension a chance to grow;
(3) It deals with the misconceptions of a rigid or defective superego. By analyzing the specific factors involved in a phobia and maturing all three psychic structures, the phobia should be eliminated, if successful. By contrast, irrational treatment methods maintain or increase patient immaturity.
A magic ritual may release forbidden impulses. Magical threats or actual punishments may temporarily suppress instinctual temptation and relieve phobia. A phobic child, for instance, can be made to go to school in such a way because he or she is afraid.
Is it necessary to treat every phobia?
Many people live with minor phobias. They neither seek nor need medical help. Help is usually sought at some transitional point. Either the patient has emerged to some degree from a state of mental disturbance and wishes to be rid of the interference that a phobia imposes on living, or he is feeling the threat of the expansion of his phobia into areas vital to his living. A diagnostician should determine whether and how a phobia should be treated after evaluating the underlying conflict. The answer to this question depends on the treatment goal and the method used.
Is it ever beneficial to allow the patient to enter phobic situations during treatment?
The goal might be just to hold the line, i.e., to contain or respect the phobic situation. The treating physician might try to narrow the phobic situation through persuasion and encouragement. The patient may cooperate based on trust in his physician’s protective power. In psychoanalytic treatment, there comes a time when sufficient understanding has developed of the emotional and irrational nature of the elements composing the phobia.
This is so that, either spontaneously or with encouragement, the patient faces the situation he has avoided up to this point. If the analysis is to be considered complete, this must happen. Entering the phobic situation will also reveal some previously hidden facets of the unconscious conflict. Also, has a patient become more able to tolerate tension? Nothing will convince anxiety of his strength unless he confronts his phobic object or situation; nothing does success.
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